It was the impact of childhood sexual abuse trauma which gave Professor Vincent Felitti and colleagues the first, vital clues to persistent poor health and unhealthy behaviours in adults. It was the trigger to the range of ACE studies they then conducted, and to numerous others held internationally ever since.
People kept dropping out of Felitti’s obesity clinic despite successfully losing weight, because weight gain, he discovered, provided several protective ways of coping with their child sexual abuse (CSA) trauma. The team’s unexpected findings of high rates of CSA, even among the largely white, middle class, educated, employed, economically-comfortable members of the Kaiser Permanente health maintenance organisation, also suggested that this traumatic experience might be widespread among people of all backgrounds.
The uncritical adoption of ACEs in public policy has been criticised, particularly when that policy adopts the original ten ACEs without including structural impacts on health, through poverty, homelessness, unemployment, racial discrimination and other social determinants of health. ACEs are often viewed as a recent, startling discovery: yet such structural impacts have been widely known and evidenced through research for many decades, involving the World Health Organisation and other global action to reduce social and racial inequalities in health (WHO). They did not appear among the original ACEs precisely because of the nature of Kaiser Permanente’s client group: Felitti and colleagues drew up the ten most common adversities among their large cohort of middle class clients.
Just as with structural inequalities, the considerable risks to health of childhood sexual abuse trauma have also been widely researched and evidenced for decades, more so than any other of the original ten ACEs. A large volume of published research exists, particularly on a wide range of mental health risks, and increasingly in recent years on physical health ones. (Nelson 2016a). The relevance also of a CSA history to persisting substance misuse, to blot out distressing effects of the trauma; to cognitive problems damaging education and career prospects, due to neurobiological effects of chronic early stress; and to higher rates of offending, due mainly to anger, alienation and involvement in drug and exploitative commercial sex cultures, are also well researched, and connect with findings of later ACE studies. Hence those of us working with CSA trauma and its effects throughout life have long argued the importance of primary prevention of this abuse, and for changes in the ways adult survivors are regarded, diagnosed and treated in mental health and in wider health services.
This is not to downplay the impact of other forms of trauma on many people, far less to downplay the still greater, demonstrated impact of cumulative ones, especially given growing understanding of developmental trauma in young people. But it is to argue that attempts to reduce childhood sexual abuse in society, and to address its damaging effects in adulthood, need to form and remain one of the key components of ACEs policy. And although the recent, belated emphasis on understanding the role of traumas in general in the lives of children and adults which ACEs have helped to promote is valuable and welcome, attention within that to sexual abuse remains marginal, and at times non-existent.
The key implication of the original ACE studies, and subsequent studies and surveys which did attempt to include some structural inequalities, has been primary prevention. But structural inequalities are notoriously difficult to reduce, far less to remove, requiring strong political will and wider, sustained political strategies. Childhood sexual abuse has also been seen as difficult to reduce, with the added problem of being very hard for authorities even to identify in children. Along with this has been a longstanding distaste, nervousness or even reluctance to believe the evidence among many policymakers and professionals, as Felitti himself discovered (KQED, 2018).
Thus it has been tempting for much public policy across the UK and internationally to concentrate on easier, broad goals, amelioration of the effects of a range of ACEs. Easier too to make hopeful efforts to increase general resilience in children, in schools and other settings, yet these can give little protection from serious crimes against them, due to the power dynamics involved in perpetration.
It has also seemed more interesting for many researchers – and regrettably easier for some policymakers to fit into theories which hold the poor, most especially mothers, largely responsible for their children’s wellbeing – to concentrate on deterministic interpretations of modern neuroscience, about children’s development in the womb and in the first three years of life. Most sexually abused children, incidentally, are assaulted after that time. Nor are most assaulted by their mothers.
Aside from the need for primary prevention, the other key implication from the original ACE studies was the need for changes in the way adults with ill health are listened to and treated. The original studies gave important insights into why some unhealthy adults behave as they do, and how this knowledge might shape strategies to improve their health. Yet traumatised adults have been rather surprisingly neglected in most ACEs policy (except in negative ways, as mothers who risk increasing their children’s stress). Thus, in thinking about action against CSA as part of a wider ACEs policy, we need to include young people and adults alike.
This first blog will look at the implications for children and young people.
It is very welcome that where ACEs policy is concerned, the Scottish Government has not shrunk from prevention issues purely in favour of amelioration. “We are committed to preventing ACEs and helping to reduce the negative impacts of ACEs where they occur, and supporting the resilience of children, families and adults in overcoming adversity”. (Scottish Government 2018). So what are the main current challenges to action where CSA, as a component of ACEs, is concerned?
A basic and considerable problem is the identification of child victims. That seriously undermines the accuracy and usefulness of ACEs checklists completed about children, or with them. Most children and young people do not disclose of their own accord; or not in ways that adults can understand; or only anonymously; or only in very sympathetic and protective circumstances. (Crisma et al 2004; McElvaney 2013). Most adults, including teachers, do not know, or are nervous of asking, or believe they should not ask. Perpetrators do not tell.
Social work and children’s hearing statistics show identification of CSA has been consistently falling- the figures are tiny- even though at the same time reports to police of sexual crimes against children, including online crimes, keep rising (Nelson 2016b). A recent Scottish study (Marryat & Frank 2019), using Growing up in Scotland study statistics to draw conclusions about Scottish children affected by ACEs, did not even consider CSA, since there were ‘too few cases to include’ (sic). Yet the questions used, the environment of the GUS surveys and the respondents chosen would have meant that GUS surveys have been very unlikely to reveal sexual abuse.
Any serious attempt to improve the identification of children suffering, or having suffered, CSA would require several assertive changes in our child protection practice, including more perpetrator-focused investigation, freedom from official fear of asking, close co- operation with confidential voluntary sector services for young people, and much closer liaison between action against child sexual exploitation (CSE) and trafficking, and protective work with younger children. Sexual exploitation is a form of sexual abuse, not a distinct and separate entity.
On prevention, greater support for the identification and conviction of offenders would require higher police resourcing and staffing, particularly for investigation of the burgeoning industry in child abuse images. Prevention also requires investment in creating informed, aware and involved local communities, not the sidelining of such communities in our now highly-professionalised, excluding, child protection system. Resilience, as part of a prevention strategy, needs to include specific work geared to ways in which young people might be kept safer from sexual crime.
Even amelioration of the effects of CSA and CSE, among the small minority of children and young people who are identified, would require much wider resourcing of skilled therapeutic services, and a far greater preparedness to work with trauma within Child & Adolescent Mental Health services (CAMHS). Studies such as NSPCC Scotland’s The Right to Recover (Galloway et al 2017) revealed how serious are inadequacies in existing therapeutic services for abused children, and the extent to which CAMHS services have failed to address CSA trauma. The Scottish Government is investing an additional £4 million in child and adolescent mental health services across Scotland, but they need first to ensure that these services actually accept and conduct routine, skilled work with abuse trauma.
Meanwhile in the education system, the difficult task of finding lasting alternatives throughout the country to school exclusions needs to be prioritised. Exclusion is where so many sexually abused, angry, distressed and vulnerable young people have found themselves, who are then at even greater risk on the streets, and among exploitative sex, drug and offending cultures.
Some of the points above involve willingness to carry out major changes to how protecting children has ‘always been done’. All the points above are not made as long and impossible ‘wish lists’. Nor of course can they be implemented and resourced at once. The point about what is itself a far from comprehensive summary of requirements across several key services is that if you promote an ACEs strategy as Scotland does, if you even attempt to judge and record how many ACEs young people have experienced, let alone ameliorate their trauma, you have to start showing through action from Government ministers downwards, that you have actually thought how to begin addressing individual components of ACEs.
A component, in this case, which decades of research and practice have shown to risk particularly serious and damaging effects on those who suffer it. You have to consider how wide-ranging those actions towards prevention and amelioration may actually need to be. You then have to make a long- term plan, and begin step by step to implement it.
Crisma, M., Bascelli, E., Paci, D. and Romito, P. (2004) ‘Adolescents who experienced sexual abuse: fears, needs and impediments to disclosure’, Child Abuse & Neglect, 28 (10):1035-48.
Galloway, S. Love, R. and Wales, A. (2017) The Right to Recover: Provision of therapeutic services in the West of Scotland for children and young people following sexual abuse, NSPCC.
KQED (2018) https://www.kqed.org/mindshift/49894/how-trauma-abuse-and-neglect-in-childhood-connects-to-serious-diseases-in-adults. Prof. Felitti has also described in numerous public lectures the disbelief and ridicule he faced initially from fellow professionals.
McElvaney, R. (2013) ‘Disclosure of sexual abuse:delays, nondisclosure and partial disclosure’, Child Abuse Review, DOI:0.1002/car.2280.
Marryat, L. and Frank, J. (2019) ‘Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study’, BMJ Paediatrics Open, 3 e000340.
Nelson, S. (2016a) Tackling Child Sexual Abuse: Radical approaches to prevention, protection and support, Bristol: Policy Press. Chapter 7: Physical ill health.
Nelson, S. (2016b) Tackling Child Sexual Abuse: Radical approaches to prevention, protection and support, Bristol: Policy Press. Chapter 1: From rediscovery to suppression?
The Scottish Government, Adverse Childhood Experiences (ACEs), 31 July 2018.
World Health Organisation, Social determinants of health: Tackling health inequalities through action on key sectors, https://www.who.int/social_determinants/Guidance_on_pro_equity_linkages/en/ is an example of a useful summary.